By Jim Tucker

Article by Dr Paul Hutchison

Published 0n Dominion Post Opinion Page – September 1, 2009

THE widespread confusion many men feel over the advice they receive on early detection and treatment of prostate cancer is untenable.

That a leading New Zealand urologist, Robin Smart, recently concluded ‘‘the evidence suggests that between 200 and 300 of the 600 men who die annually of prostate cancer could be saved by current technology’’ indicates greater efforts need to be made.

He says, ‘‘there have been powerful discouragements to men contemplating PSA [blood] testing, and their family doctors, resulting in uncertainty and confusion’’.

Because of this, I felt it important to launch an inquiry. This call has been taken up by Parliament’s health select committee. The inquiry is into ‘‘the early detection and treatment of prostate cancer’’. Submissions close next Monday.

About 2000 cases of prostate cancer are diagnosed each year. In a helpful but, I believe, cautious pamphlet published last year, the New Zealand Guidelines Group noted the chances of a diagnosis of prostate cancer for: A man in his 40s: 1 in 500 men. In his 50s: 1 in 50. In his 60s: 1 in 14. In his 70s: 1 in 9. What is startlingly clear is that ‘‘if you have a close relative with prostate cancer, your risk of developing cancer is increased’’.

I have no doubt that New Zealand men should be made clearly aware of the risk factors because increasingly effective diagnosis and treatment are available.

There is ongoing debate as to the optimal early detection and treatment of prostate cancer. Dr Smart wrote in the December New Zealand Medical Journal: ‘‘An overwhelming body of evidence shows that PSA, prostate specific antigen [a blood test], and digital rectal examination leading on to transurethral ultrasound biopsy and curative treatments [where indicated], has been a major advance for men’s health.’’

On screening, Dr Smart says a common argument used is that 450 men must be screened to save one from dying of prostate cancer (a figure which is disputed), and that this is too large to make screening worthwhile.

But the equivalent figure for breast cancer screening is 1700, and for cervical cancer screening 8000.

Dr Smart’s views are more closely supported by other clinicians, such as Professor David Lamb and Professor Brett Delahunt of the Wellington School of Medicine. They wrote in Pathology in 2007 that there is now compelling evidence that:

‘‘Cancers diagnosed by screening are more likely to be early stage, when most can be cured by several treatment options.

‘‘The maximum benefits for screening are for men aged 50-70.

‘‘Men with one or more firstdegree relatives already diagnosed with the disease should be actively encouraged to undergo screening.’’

Two major trials on prostate screening (one in Europe and the other in US) were published this year and were hoped to bring greater clarity to the issue.

The New Zealand Guidelines Group is due to report by November on an extensive literature review on the effectiveness of screening asymptomatic men.

Associate Professor Brian Cox, an epidemiologist at Otago University, writing in the New Zealand Medical Journal in June, concluded: ‘‘Trial evidence suggests that claims of benefit from PSA testing in asymptomatic men have probably been overstated and the recognised harms must be rigorously considered to protect men from iatrogenic (doctor caused) illness.’’

The Australian Senate received recommendations in May from its select committee inquiry on ‘‘men’s health’’.

The Australian report quoted the recommendations of the Prostate Cancer Foundation of Australia, which are that ‘‘all men from age 50 onwards would go to his GP and have a conversation about prostate cancer, they should have the blood test, the PSA, and they should have a physical digital rectal examination to feel whether there is any growth in the prostate’’.

The report concludes: ‘‘Prostate cancer is the most diagnosed cancer in Australia. At present the information available to those with prostate cancer and the services to support them are not adequate.’’

The same situation exists here. The New Zealand Prostate Cancer Foundation is responsible for an awareness campaign, Blue September, starting now.

While it is wrong to raise unrealistic expectations, the aim of stronger action is to avoid preventable deaths. I believe it is fundamental that New Zealand men are able to receive the best possible evidenced-based advice in a clear, concise way.

Dr Paul Hutchison is MP for Hunua and chairman of the parliamentary health select committee.

NZ Parliament’s more recent brushes with prostate cancer

JULY 20, 2009: PROSTABLOG NZ: New Zealanders have until August 21 to make submissions to the world’s only current parliamentary inquiry into prostate cancer screening.

Terms of reference for the inquiry by the Health Select Committee were announced today. The committee seeks:

1. A summary of the contemporary literature on the subject including, incidence, mortality, groups at risk, testing options (with particular reference to age and family history, treatment and what other countries are doing).

Announcing the decision, the committee said it would release terms of reference after its next meeting on Wednesday next week (June 24).

Green Party MP Kevin Hague, a member of the committee, disagreed with the decision: “When politicians start making complex medical decisions, it’s dangerous and a recipe for disaster,” he said. “This is not the best way to develop health policy.”

Parliament’s select committees can hold inquiries into anything they want to and the health committee has carried out several in recent years.

20 Aug 2008: Barbara Stewart to the Associate Minister of Health: Is the Minister aware of the Cancer Control Council’s concern about the lack of progress in assessing the extent to which late detection and diagnosis of cancer contributes to New Zealand’s high mortality rates; if so, what is he doing to rectify this?

Hon Damien O’Connor (Associate Minister of Health) replied: I am aware that a year ago the Cancer Control Council noted concerns regarding the detection and diagnosis of cancer in its August 2007 report ‘Mapping Progress: The First Two Years of the Cancer Control Strategy Action Plan 2005-2010’.

New Zealand’s overall cancer survival rates are high by international standards. Over the next ten years, mortality rates are projected to fall for almost all major and minor cancers in most age groups for both sexes, with much of the forecast improvement resulting from improvements in survival through earlier and more effective treatment. (Ministry of Health. 2008. ‘Cancer Mortality Projections 2000-2004’ update).

However, research commissioned by the Ministry of Health has identified delayed access to detection and diagnosis as a key factor in cancer inequalities, especially for Maori.

A number of initiatives are under way aimed at early detection and diagnosis. These include:

the development of Access and Referral Guidelines for Primary Care to enhance access to secondary and other services from primary care;

guidance for general practitioners, men and their families on prostate testing for early detection of prostate cancer;

Melanoma Guidelines (which include guidelines on detection);

a national bowel cancer screening programme;

and a focus on reducing disparities in uptake of the breast and cervical screening programmes for Maori and Pacific women.

29 May 2008:Barbara Stewart to the Associate Minister of Health: Does he consider that the current level of public awareness of prostate cancer screening is sufficient; especially the fact that men who have a close relative with prostate cancer have a greater chance of developing it; if not, what is his ministry doing to improve public awareness?

Hon Damien O’Connor (Associate Minister of Health) replied: No, which is why the Ministry will be improving access to updated information on prostate cancer testing. Guidance material for both clinicians and the public on prostate cancer testing, which is based on current evidence and Australian guidelines, is to be released by 31 August 2008.

In addition, general practitioners will be offered training on the guidelines from 1 August 2008 and two reviews will be completed by 30 June 2009: -a review of the existing international evidence for the efficacy of using prostate screening tests -a review of the New Zealand rate of complications accompanying prostate biopsy and prostate cancer treatments.

May 20, 2008: Barbara Stewart: What steps has the Government taken to increase protection for men from the risk of prostate cancer, considering that the number of deaths annually from this type of cancer is now greater than the annual New Zealand road toll?

Hon STEVE CHADWICK: When we have access to good new technologies that are cost effective and have proven benefits then we should use them. To date, the expert clinical advice is that technology is not effective enough to support a prostate cancer screening programme. However, if men are concerned about their health they should talk to their family doctor or nurse.

04 Mar 2008: Judy Turner to the Associate Minister of Health: Has any action been taken to review the guidelines for screening for prostate cancer in the past 12 months; if not, why not; if so, what action has been taken and what have been the results?

Hon Damien O’Connor (Associate Minister of Health) replied: I am advised that the Ministry of Health, in conjunction with the Prostate Cancer Foundation, are currently reviewing the guidance available to men and doctors regarding the decision to have testing for prostate cancer. The Ministry has not changed the recommendation for a population screening programme; however it does support testing on an individual basis after consultation with the person’s general practitioner.

09 Aug 2007: Rt Hon Winston Peters to the Minister of Health: What reports, if any, has the Minister received regarding prostate cancer or prostate cancer screening, specified by title and date?

Hon Pete Hodgson (Minister of Health) replied: I have not received any specific reports on prostate cancer or prostate cancer screening.

09 Aug 2007: Rt Hon Winston Peters to the Minister of Health: Has the Ministry of Health conducted any information campaigns relating to prostate cancer or prostate cancer screening since 2000; if so, what is the value of funding for each campaign since 2000, broken down by financial year ?

Hon Pete Hodgson (Minister of Health) replied: No.

07 Jun 2007: Dr Jackie Blue to the Minister of Health What are the latest confirmed figures for prostate cancer registrations and deaths and the year it relates to; what is the latest provisional figures for prostate cancer registrations and deaths and the year it relates to?

February 27, 2007:Dr Jackie Blue: Can the Minister guarantee that updated breast cancer surgical guidelines will be forthcoming, or will it be like the long-awaited update of the prostate cancer guidelines on the Ministry of Health website, which were promised 16 months ago but still nothing has happened?

Hon PETE HODGSON: The guidelines are under development now.

October 16, 2006: Dr Jackie Blue to the Minister of Health (16 Oct 2006): Has any preliminary work been done by the Ministry of Health on the costing and logistics of a prostate cancer screening programme; if so what are the results of any preliminary work?

Hon Pete Hodgson (Minister of Health) replied: In April 2004 the National Health Committee (NHC) published its report to the Minister of Health on prostate screening in New Zealand. The report did not recommend population based screening for prostate cancer. No further work has been done by the Ministry of Health on the costing and logistics of an organised population based screening programme.

Dr Jackie Blue to the Minister of Health (16 Oct 2006): When did PSA or prostate specific antigen testing become available in New Zealand?

Hon Pete Hodgson (Minister of Health) replied: The Ministry of Health is not aware of the exact date the PSA test became available in New Zealand. However, statistics in the publication Cancer Trends and Projections indicate that the PSA test was being more widely used from the 1990s onwards.

Dr Jackie Blue to the Minister of Health (16 Oct 2006): How does New Zealand’s current prostate cancer screening guidelines compare to Australia, United Kingdom, United States, Canada and European countries?

Hon Pete Hodgson (Minister of Health) replied: New Zealand’s current policy on prostate cancer screening is the same as Australia, United Kingdom, United States, Canada and European countries, and aligns with the recommendations of the World Health Organization.

Dr Jackie Blue to the Minister of Health (16 Oct 2006): Have the interim results of the prostate cancer screening trials involving hundreds of thousands of men in Europe and the United States been made available to the Ministry of Health; if so, what are the preliminary results; if they are not available, when are they expected to be available?

Hon Pete Hodgson (Minister of Health) replied: The Ministry of Health is aware of two large randomised trials occurring in Europe and the United States. The first interim results of these studies are expected by the end of this year.

Dr Jackie Blue to the Minister of Health (16 Oct 2006): What resources does the Ministry of Health provide to General Practitioners regarding prostate cancer screening; when were they last updated?

Hon Pete Hodgson (Minister of Health) replied: The Ministry of Health has published a pamphlet Screening for Prostate Cancer for health care practitioners, which is currently being updated. The pamphlet was produced by the New Zealand Guidelines Group in 2004 and is available on the Group’s website (www.nzgg.org.nz).

Dr Jackie Blue to the Minister of Health (16 Oct 2006): What are the current guidelines for prostate cancer screening; when were these last updated?

Hon Pete Hodgson (Minister of Health) replied: There are no New Zealand guidelines for prostate cancer.

May 9, 2006:Barbara Stewart to the Minister of Health (09 May 2006): Has a decision been made with regard to the establishment of a brachytherapy service for Wellington; if not, why not; if so, when will the service start?

Hon Pete Hodgson (Minister of Health) replied: The establishment of a high dose rate brachytherapy unit at Capital and Coast District Health Board that provides services to the Lower North Island and the South Island for the treatment of prostate cancer has been agreed. The service will commence when Capital and Coast District Health Board has received confirmation of the agreement of all district health boards to fund high dose rate brachytherapy and agreed a business case for its introduction.

August 2, 2005: Petition of Dr Muriel Newman and 585 others – requesting the introduction of a national prostate cancer screening programme for men.

May 19, 2005: Phil Heatley to the Minister of Health (19 May 2005): What funds have been allocated for prostrate and/or testicular cancer research, treatment or screening in each of the years from 2000 to 2004?

Hon Annette King (Minister of Health ) replied: Research Funding may be allocated for prostate and testicular cancer research through the Health Research Council (HRC). As HRC is funded through Vote Research Science and Technology, I refer the member to PQ 6416 (2005).

Treatment: As treatment for cancer is covered by Section 26 of the New Zealand Public Health and Disability Act 2000, this part of the question is best addressed to each district health board.

Screening:Screening for prostate cancer occurs in primary care at the request of the individual patient. The Prostate Specific Antigen (PSA) test is funded through district health board community laboratory agreements and follow up diagnosis and treatment funded as for other cancer diagnosis and treatment services (see treatment above).

As recommended by the National Health Committee there is no national organised screening programme for prostate cancer.

November 12, 2004: Dr Muriel Newman to the Minister of Health (12 Nov 2004): How does the reliability of the Prostate Specific Antigen (PSA) test as a predictor of prostate cancer compare with the reliability of mammography results for the breast cancer and pap smears for cervical cancer?

Hon Annette King (Minister of Health) replied: It is difficult to give a simple answer to this question. Firstly, PSA tests, mammograms and pap smears are very different types of test. A PSA test is a blood test, which gives a blood level for each person tested. The sensitivity (the proportion of people with the disease who are detected as having it by the test) and the specificity (the proportion of people without the disease who are correctly reassured by a negative test) depend on the ‘cut-off’ value used.

A cervical smear depends on a viewer assessing a slide of cervical cells, so it is a more subjective judgment (as is a breast mammogram). Additionally, a cervical smear is not trying to detect cervical cancer, but changes in the cervix that might (at some future time) turn into cancer.

The sensitivity and specificity of tests also vary by a number of factors. For example, the sensitivity and specificity of a mammogram will depend on the age of the woman, her breast density, the use of hormone replacement therapy (HRT), the quality of the mammogram image, the number of views taken, the number of mammogram readers, and the experience and skill of the reader.

Thus, comparing the relative validity of the tests by themselves is not particularly helpful. However, as a best estimate, a single cervical smear detects about 60 to 80 percent of high-grade lesions (sensitivity), with specificity over 90 percent.

It is not possible to derive exact estimates of the sensitivity and specificity for PSA tests.

The best estimates for the PSA test, however, are 74–84 percent sensitivity, and 90–94 specificity, with the lower values in the range most likely to be the true values. A recent meta-analysis of breast screening estimated the sensitivity of mammography at between 71 and 96 percent, and the specificity at between 94 and 97 percent.

Dr Muriel Newman to the Minister of Health (12 Nov 2004): What are the details of any peer reviews that occurred with regard to the research carried out to determine whether or not a national screening programme for prostate cancer should be established, who took part in those reviews and on what specific date did official meetings take place?

Hon Annette King (Minister of Health) replied: The advice received by the expert advisory group is subject to a full, public consultation process. The National Health Committee used its own internal peer review processes to consider its advice to the Minister of Health. This was done at monthly National Health Committee meetings, together with specific sponsor meetings, throughout 2003 until the launch of the advice in April 2004.

November 11, 2004: Dr Muriel Newman to the Minister of Health (11 Nov 2004): Is the government currently considering a national screening programme for prostate cancer; if not, why not?

Hon Annette King (Minister of Health) replied: Consistent with all other countries, the Ministry of Health is not currently considering a New Zealand national screening programme for prostate cancer.

The National Health Committee’s advice clearly outlines that there is still no conclusive evidence to demonstrate that screening for prostate cancer reduces mortality or morbidity.

There is, however, evidence of the potential for harm from the screening pathway. The Ministry of Health does not support population-based screening for prostate cancer or opportunistic screening for men in New Zealand at this time. However, the Ministry of Health is keeping well informed of any new evidence on the benefits and harms of prostate cancer screening.

Two large randomised controlled trials on prostate cancer screening are due in 2010, and the Ministry will formally reassess prostate cancer screening once these trials are completed.

November 10, 2004: Dr Muriel Newman to the Minister of Health (10 Nov 2004): Have estimates of the cost of a national screening programme for prostate cancer been carried out; if so what is the estimated cost?

Hon Annette King (Minister of Health) replied: No.

September 14, 2004: Dr Paul Hutchison to the Minister of Health (14 Sep 2004): Does the Ministry of Health have a view on the value of initiating a ‘prostate awareness’ campaign; if not why not?

Hon Annette King (Minister of Health) replied: Yes. The Ministry supports the views of the National Health Committee which does not recommend prostate screening for asymptomatic men because of its lack of proven benefit and the potential for harm arising from unnecessary radiotherapy, surgery or other treatment at this stage but we will continue to monitor international trends and research.

The committee has, however, published information regarding issues men need to consider when seeking prostate screening tests in the brochure Checking for Prostate Cancer, Information for men and their families. This brochure is available on the New Zealand Guidelines Group’s website: http://www.nzgg.org.nz.

Dr Paul Hutchison to the Minister of Health (14 Sep 2004): Is she satisfied that the April 2004 report of the National Health Committee relating to prostate cancer screening provided up to date and best practicre advice; if not why not?

Hon Annette King (Minister of Health) replied: Yes.

Dr Paul Hutchison to the Minister of Health (14 Sep 2004): What specific public health programmes are available to alert men to health problems such as prostate cancer; if there are none, why not?

Hon Annette King (Minister of Health) replied: There are no specific health programmes to alert men to prostate cancer because routinely checking men without symptoms of prostate cancer is not recommended. However, I refer the member to written question No 13279 regarding the National Health Committee and New Zealand Guidelines Group’s brochure on this issue. For initiatives in other health programmes, I refer the member to written question No 13269 (2004).

Dr Paul Hutchison to the Minister of Health (14 Sep 2004): What advice does the Health Ministry recommend to men, specifically to help prevent and achieve early detection of prostate cancer, and if not why not?

Hon Annette King (Minister of Health) replied: The Ministry of Health endorses the guidance produced by the National Health Committee, which states that men who have concerns should see their GP. These guidelines are available on the National Health Committee website (http://www.nhc.govt.nz/publications.html).

April 7, 2004: Dr Muriel Newman to the Minister of Health (07 Apr 2004): What reports or advice, if any, has the Ministry prepared regarding screening for prostate cancer, specified by title and date?

Hon Annette King (Minister of Health) replied: As the National Health Committee (NHC) has had the lead on this issue, the Ministry of Health has not prepared separate reports or advice but has provided input into the NHC work where relevant. The issue of prostate cancer screening has been reviewed twice by the NHC, with initial advice to the Minister of Health in 1996 (Prostate Cancer Screening: Issues Explained and Screening for Carcinoma of the Prostate). This advice was updated in April 2004.

Dr LYNDA SCOTT (National—Kaikoura) : It is with pleasure that I rise to speak on the Health (National Cervical Screening Programme) Amendment Bill…

…So I believe that New Zealand women can have confidence in this programme and in confidentiality with their general practitioner.

Its expansion to other screening programmes was considered to be not appropriate. It was felt that this bill should be about the specific programme it was dealing with—that is, the National Cervical Screening Programme—and that if we needed other legislation, say, for the breast-screening cancer programme, or if at some time in the future we develop a screening test for prostate cancerthat has more reliability and validity, then that also would need to go through the House as a separate bill rather than have expansion of the bill we are debating tonight.

The reason that prostate canceris not part of a routine paid-for screening programme is that the test, which is the prostatic sensitive antigen test, is not specific enough and has a high rate of false positives and false negatives.

With screening programmes such as the cervical-screening programme or the mammography programme, there is a high level of certainty that one will pick up the changes that may lead to cancer further down the track; also that the treatment one can then offer can effectively reduce the mortality—and that occurs both in cervical cancer and in breast cancer.

But I am sure that most men in New Zealand are really hoping that a test will be developed in the future that has that sort of specificity for prostate cancer, as that is one of their leading causes of death.

July 28, 2003: Dr Muriel Newman to the Minister of Health (28 Jul 2003): Are there any public prostate cancer screening programmes; if not, why not?

Hon Annette King (Minister of Health) replied: There is no publicly funded prostate cancer screening programme because there is no good evidence that screening for prostate cancer reduces morbidity and mortality from prostate cancer.

Presently, no country has a prostate cancer screeningprogramme. The answer to the question of whether or not prostate cancer screening is worthwhile awaits the results of randomised controlled trials underway in Europe and the USA, which are due to report in 2005.

Men are currently able to have a publicly funded prostate specific antigen test if they wish to, and publicly funded diagnostic and treatment services are available for men who are found to have prostate cancer.

BARBARA STEWART (NZ First) : I am pleased to speak to the Health (Screening Programmes) Amendment Bill. New Zealand First will support the referral of the bill to the select committee. It is a very worthy bill and it is long overdue…

…We are pleased to note in the bill that the system will be set up so that it can be extended. New Zealand First would like to see those screening programmes extended at some later date to include, for example, prostate cancer, hepatitis B, asthma, diabetes, and osteoporosis. We believe that it is in the best interests of all New Zealanders that the screening programmes are extended to include those diseases, and perhaps even more, at some later date.